A charge nurse is evaluating a newly licensed nurse caring for a client who is using a PCA device.
Which of the following actions by the nurse requires intervention by the charge nurse?
The nurse asks the client to demonstrate dose delivery.
The nurse administers a PCA dose for the client.
The nurse reassures the client that the PCA device will not cause an overdose.
The nurse monitors the client for oversedation.
The Correct Answer is B
Choice A rationale:
Asking the client to demonstrate dose delivery can be part of patient education and helps ensure that the client understands how to use the PCA device. This action does not require intervention.
Choice B rationale:
The nurse administering a PCA dose for the client requires intervention. PCA stands for “Patient-Controlled Analgesia,” meaning that only the patient should administer doses to themselves. This prevents overdosing and ensures that pain medication is administered according to the patient’s needs.
Choice C rationale:
Reassuring the client that the PCA device will not cause an overdose is appropriate because PCA devices are designed with safety measures to prevent overdosing.
Choice D rationale:
Monitoring for oversedation is an important part of care for a client using a PCA device. This action does not require intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice Arationale:
Flaxseed is a rich source of omega-3 fatty acids and can have anti-inflammatory effects. It does not have any known contraindications with SLE.
Choice B rationale:
Glucosamine is often used to support joint health. It is not contraindicated in clients with SLE and may actually provide some benefits in terms of reducing joint pain and stiffness.
Choice C rationale:
Echinacea is an herbal supplement that is often used to boost the immune system. However, in clients with autoimmune disorders like SLE, boosting the immune system can actually exacerbate the disease. Therefore, Echinacea is contraindicated in clients with SLE.
Choice Drationale:
Ginger is a common herbal supplement that is often used for its anti-inflammatory and anti-nausea effects. It does not have any known contraindications with systemic lupus erythematosus (SLE)
Correct Answer is C
Explanation
Choice A rationale:
Pinching the tube while connecting the syringe to it could potentially damage the tube and does not aid in medication administration.
Choice B rationale:
Elevating the head of the client’s bed to only 10° may increase the risk of aspiration. The head of the bed should be elevated to at least 30° during medication administration and for at least an hour afterward.
Choice C rationale:
Flushing the tube with normal saline following medication administration helps ensure that all medication has been administered and helps maintain tube patency.
Choice D rationale:
Combining crushed medications together in a single syringe can lead to drug interactions and can also increase the risk of tube clogging. Each medication should be administered separately.
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